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Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Leslie B, Marshall MC USN (RET) - Editor 



V61. 33 



Friday, 22 May 1959 



No. 10 



TABLE OF CONTENTS 

The Abortion Problem 2 

Pregnancy after Ligation of the Inferior Vena Cava 7 

Asian Influenza A in Boston 1957 - 1958 9 

Pulmonary Abscess 11 

Pulmonary Function in Bilateral Resection 14 

Laryngeal Trauma and Its Complications 16 

Chelating Agents in the Therapy of Berylliunn Poisoning 19 

From the Note Book 21 

American Board of Obstetrics and Gynecology 23 

Shipboard Pest Control - New Training Film 23 

DENTAL SECTION 

Dental Cutting Procedures 24 

Dentlst-Popvilation Ratios 25 

American Academy of Oral Pathology Elects New Officers 25 

Board Certifications 25 

RESERVE SECTION 

Two Weeks' Course in Military Entomology , 26 

Naval Reserve Medal 26 

PREVENTIVE MEDICINE SECTION 

Preventive Medicine in Infectious and Noninfectious Disease 28 

Salmonella Infections in Children' s Wards 31 

Selected Materials on Staphylococcal Disease 31 

New Four in One Antigen 34 

Venereal Disease Epidemiologic Report 34 

Basic Facts for Safe Boat Trailing 34 

Dishwashing Machine Operation Aboard Ship 36 

Benefits of Golf 38 

U. S. Naval Medical Research Unit No. 2 39 



Medical News Letter, Vol. 33, No. 10 



Policy 



The U. S. Navy Medical News Letter, is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged 
to obtain the original of those items of particular interest to the individual. 

The Abortion Problem 

The frequency of spontaneous abortions is not accurately known. This 
information is difficult to obtain because many women — especially those who 
have already had several children — often do not consult a doctor when they 
know they are having an abortion unless they become alarmed by the bleed- 
ing. Even if every woman who lost a pregnancy consulted a physician, there 
would still not be an accurate figure because some pregnancies end before 
the woman knows that she is pregnant. 

Among women admitted to a hospital, the number who abort seems to 
be fairly constant around 10%. A study of six American cities made in 1950 
showed a variation from 7. Z to 10. 7% with an average of 9. 7%. This sanne 
percentage is found at the Chicago Lying-in Hospital where, among 10,818 
patients admitted in the last 3 years, 1057 were recorded as having spontan- 
eous abortions. When 3342 of these women who had already had at least one 
pregnancy were carefully questioned about past spontaneous abortions or 
deaths of fetuses before birth, it was found that they had had a total of 6804 
pregnancies. Of these, 19% had ended in abortion and in an additional 4% 
the child was born dead or died soon after birth. These women had, con- 
sequently, lost almost one -fourth of their pregnancies. 

The difference in the proportionate number of pregnancies ending in 
spontaneous abortion as obtained by history and direct observation of patients 
in a hospital is believed to be due to the large number of women who abort 
but do not require hospitalization. 

Because of the patient's reluctance to acknowledge a criminal abortion, 
it is not always possible to tell how many abortions thought to be spontaneous 
may actually be a result of this procedure. The Kinsey report showed that 
only 17% of women having criminal abortions are subsequently hospitalized. 
One-third of these had the type of severe infection that can usually be recog- 
nized as caused by criminal abortion. Even if it were assumed that none of 



Medical News Letter, Vol. 33, No. 10 



the criminal abortions were recognized as such and were thought to be spon- 
taneous, it would alter the frequency of those observed in any hospital by 
less thaji 3% of the, total deliveries — ^if the Kinney figures are correct. 

If a 2% lo^s from stillbirth is added to (!) the 20% figure arrived at by 
Bautngartner and Erhardt, {2) the 19% rate noted by the Chicago Lying-in 
Hospital figure, or, (3) the Kinsey Institute figure of 17%, the tptal loss before 
birth (ejccluding criminal abortions) is. at least 20% of conceptions. Ii> 1955, ; 
4, 104, 112 infants were born alive in the, United States. If one--fifth of the 
total number of pregnancies terminate in the delivery of a dead fetus,, there 
is the staggering j;ot,al , of opie million such deaths. And, if the Kinsey r^.port . 
represents .an adequate- sarriiple, another million babies are intentionally .-^rr., 
sacrificed. .j 

Knowing, the approximate number of spontaneous abortions, the next 
question is "What is the cause?" In an individual case this is difficult to 
determine. Jeffcoate and Wilson of the University of Liverpool say that a 
specific cause can be found for only 15% of abortions. Most other investiga- 
tors add that their figures are not much higher than this. 

The uterus will not hold a pregnancy for more than a few weeks unless 
it is fairly normal. If the embryo dies or is sufficiently abnormal, the uterus 
will expel it. The embryonic sac develops normally only when it contains an 
embryo, but it may actually grow for about 3 months with a very abnormal 
embryo or with none at all. For this reason, more abortions occur at 10 
to 14 weeks than at any other time. 

To find how many fetuses were aborted because they were abnormal 
and how many because of some other condition, Hertig and Livingston exam- 
ined the material passed during the course of 1000 abortions. This is impor- 
tant in order to know whether an attempt should be made to prevent an abor- 
tion when symptoms first appear or whether it would be better to let nature 
take its course. With a sufficiently abnormal pregnancy, treatment would 
do nothing except delay the inevitable expulsion, 

Hertig and Livingston found that only 26% showed anatomically normal 
embryos and that not more than two -thirds of these were alive when the 
patient was first seen by a doctor. In the majority, the sac contained no 
embryo or only a stunted rudiment. 

The author examined similar material from 1500 women at the Chicago 
Lying-in Hospital and foiand the number of normal embryos even less. In only 
20% were normal embryos present and over one-half of these had been dead 
for a considerable period of time prior to abortion. Probably less than 10% 
of the total could have been saved by any form of treatment. 

The symptoms indicating that a pregnancy is in danger of being lost 
are bleeding and uterine cramps. The first symptom is usually bleeding. 
What proportion of women who have bleeding early in pregnancy abort and 
what proportion finish pregnancy with a normal baby? 

In a study of 5000 women who had a baby at the Chicago Lying-in 
Hospital, 488 (about 10%} had some bleeding during the first 6 months. About 



Medical News Letter, Vol. 33, No. 10 



three-fourths of this occurred in the first 3 months. In 90%, pregnancy ended 
in the birth of a living mature infant; in 5%, a living premature infant; in only 
5% did the child die. Simultaneously, there were 491 women admitted to the 
hospital with similar symptoms who did abort. This almost equals those who 
threatened to abort but did not. The authors conclude that in about one-half 
of the women the symptoms grew worse and the abortion was completed. In 
the other half, they subsided and a normal infant was subsequently delivered. 

If abnormal development is responsible for abortion, the abno.rmality 
maybe intrinsic in the egg or sperm, or maybe a result of the en-vironment 
in which growth takes place. If the cause is intrinsic, it must be something 
inherited or something injuring the egg or sperm before or at the time they 
unite. 

Even though disease of the endometrium is no longer thought to be res- 
ponsible for abnorn:>al development, other conditions may adversely affect 
a young embryo. Local infection can rarely be demonstrated as a cause, 
but generalized infections — especially those producing high fever such as 
typhoid fever— may lead to death of the embryo. Brucellosis may cause 
abortion in mares, cows, and other animals, but has never been known to 
produce abortion in women. Syphilis maybe responsible for stillbirth, but 
it probably does not cause abortion. 

Although viruses rarely have been found to cause abortion in humans, 
they may cause abnormality in development. The action of rubella is best 
known. It is also possible that virus not yet recognized may lead to very 
early embryonic death. Poliomyelitis is one of the few viral diseases that 
has been carefully studied and an increased frequency of abortion has been 
found. 

Certain poisons may cause abortion, notably lead. In 1905, when the 
harmful effect of this mineral was just being recognized, the French Depart- 
ment of Labor reported that 60% of 1000 pregnancies in lead workers resulted 
in abortion. Poisoning of either the father or the mother gives the same 
result and abortion is probably due to the very early death of the embryo. 
After recovery from lead poisoning, pregnancies again become normal. 

Many conditions have been suggested as occasional causes of abortion. 
Among these are incompatibilities between blood groups of mothers and in- 
fants. Actually, there is no evidence that either AB or Rh incompatibility 
is a cause of abortion, In some instances, abortions appear to be the cause 
of maternal isoimmunization, inasmuch as certain studies have shown that 
more than an average number of abortions occur prior to the first recogni- 
tion of Rh immunization, but not afterward. 

A growing interest in psychosomatic medicine has led to an increasing 
interest in the possible role of the emotions in producing, abortions. Whether 
this contributes to the production of an abnormal embryo or leads to direct 
expulsion of a normal embryo has apparently not been discussed. 

Because there is a well established relationship between emotions and 
menstruation and emotions and fertility, there is a belief that a relationship 



Medical News Letter, Vol. 33, No. 10 



between emotions and abortions must also exist. Disturbances primary in 
the uterus that have been occasionally thought to contribute to early termina- 
tion of pregnancy include: underdevelopment or malformation of the uterus; 
backward displacement; tumors commonly known as "fibroids"; and a weak 
cervix which relaxes and lets the pregnancy protrude. Trauma, such as a 
severe blow on the abdomen, may injure a child late in pregnancy but prob- 
ably almost never causes an abortion. Travel by any mode of transportation 
has been definitely disproven to cause abortion. 

It is evident that because many abortions have their origin extremely 
early — sometimes even before pregnancy is recognized — prevention, to be 
effective, must begin before conception occurs. To have the fewest possible 
unsuccessful pregnancies, every man and woman about to have a child should 
be in a state of maximum physical and emotional health and should lead lives 
temperate in all things. Because there are miany causes of abortions and in 
any particular case it is often impossible to determine the cause while the 
abortion is still in progress (or for that matter, even after it is completed), 
and because most often the next pregnancy proceeds to a normal termination, 
there are many arguments in favor of permitting a continuance of a normal 
way of life during the time abortion threatens. 

The majority of physicians realize that when bleeding is due to some 
cause other than an impending abortion, it will ordinarily subside spontan- 
eously and any treatment given generally will make no difference in the out- 
come. Often, it is felt that women need some type of treatment for the psy- 
chologic effect it exerts. Some women expect to be told to stay in bed and 
to be given some variety of hormone; if such a recommendation is not nnade, 
the majority will consult another doctor. 

When a woman has had one abortion, it is generally attributed to chance, 
that is, she is thought to have temporarily experienced some one of the con- 
ditions causing the abortion, "When she has had three abortions, she is gen- 
erally put in a special group called "habitual aborters, " in the belief that she 
has some condition that is repeating itself and is keeping her from carrying 
a pregnancy a normal length of time. 

Many years ago, Malpas examined the records of patients who had had 
several abortions and concluded that after a woman had had three she had only 
a 27% chance of normal pregnancy in the fourth. Later, Eastman gave such 
a woman only a 16% chance of a normal pregnancy. 

More recently, Speert decided that neither of these conclusions was 
based on sufficient evidence. He studied the records at the Sloane Hospital 
in New York and found that among 121 women who had had three or more 
spontaneous abortions, 81% had a living child in the next pregnancy regard- 
less of the variety of treatment or whether any treatment at all was given. 

In spite of Speert' s report, most investigators who try out various 
procedures to prevent abortion quote Eastman's figures and consider that when 
more than 16% of women have a successful pregnancy after having had three 
abortions, the treatment they have prescribed must have been responsible. 



Medical News Letter, Vol. 33, No. 10 



Too often, in looking for a cause of habitual abortion, it seems to have 
been assumed that all abortions in this category must be due in all women to 
a single cause and that if it could be found, all could be prevented. One cetn 
be surprised at the many different forms of treatment that have been tried 
and also at the large share that have been reported as being about 80% suc- 
cessful. This great variation in treatment gives evidence of how unsatisfac- 
tory any course yet recommended has been in preventing abortion in all 
women and suggests that women who seem to abort habitually are actually 
no different from other women, that in about 15 to Z0% of all pregnancies 
abortion will occur regardless of treatment and whether or not there have 
been previous abortions. 

The fact that so many methods of treatment have been reported to give 
about 80% success has led sonne doctors to conclude that there may be no 
specific treatment that affects the course of a pregnancy and that whatever 
effect may be obtained is of psychosomatic origin. The patient's symptoms 
are allayed by the confidence the physician's words engender when he tells 
her that his treatment will prevent abortion. 

Also, there are physicians who are somewhat less optimistic about the 
effect of any treatment — even psychosomatic— and point out that in cases 
where no treatment of any kind has been given the outcome is just as satisfactory. 

The one point on which there is almost complete agreement is that 
when bleeding begins, it is already ordinarily too late for any variety of 
treatment to do much good. To be effective, any treatment designed to pre- 
vent abortion must be instituted before pregnancy begins. This means 
preconceptional care. 

Preconceptional care has the same relation to prevention of abortion 
that prenatal care has to the prevention of perinatal mortality. To be suc- 
cessful, both must be instituted before difficulties begin. More and more 
attention is being given to the need for preconceptional care and in some 
places clinics are being established for such a purpose. Some doctors like 
Aaron and his colleagues do not refer patients to these special clinics until 
after two abortions, while others believe that every woman wajiting to have 
children should have a thorough examination and the benefit of good medical 
care before first becoming pregnant. 

Premarital examinations are required in many states to determine the 
possible existence of venereal disease. Ideally, all couples about to be 
married would have a real examination that would determine their fitness to 
become parents from both psychologic and physical aspects, and which would 
permit correction of remediable factors before or soon after marriage. Only 
in such a way can a decrease in the number of abortions in first pregnancies 
be hoped for. 

"When a woman has had an abortion, the attempt to prevent a repetition 
should be made before the beginning of the next pregnancy — not after the 
symptoms appear. Preconceptional care can be expected to decrease the 



Medical News Letter, Vol. 33, No. 10 



number of abortions, just as prenatal care has decreased the number of 
stillbirths and infant deaths. Abnormalities of the uterus may be corrected, 
inadequate thyroid secretion can be replaced, and vitan^in deficiencies can 
be overcome. It can even be hoped that abnormal development of the embryo 
and its sac may be prevented by improving the total health of the patient. 
(Potter, E. L. , The Abortion Problem: GP, XIX : 105-113, April 1959) 

ij^ ^ ;^ iff 7^ ;ii: 

Pregnancy after Ligation of the 
Inferior Vena Cava 

The authors report their observations of 47 instances of pregnancy 
subsequent to ligation of the inferior vena cava and ovarian vessels. Since 
1941, members of their department have ligated the inferior vena cava and 
ovarian veins of 140 women. Twenty -three of these women are known to 
have become pregnant subsequent to ligation. 

The case histories indicate that 22 of these patients conceived within 
48 months of ligation. One patient did not conceive until 84 months after 
operation. The earliest conception was within 4 months. The authors enn- 
phasize that these 23 women had had severe infection of the pelvic vessels 
and uterus and that medical regimen had failed to overcome the infections. 
Ligation of the inferior vena cava and ovarian veins was done as a life-saving 
procedure. 

Pregnancies that were carried successfully beyond 28 weeks were con- 
sidered viable. These 23 women had 47 pregnancies after ligation of the 
inferior vena cava and ovarian veins. Thirty of these pregnancies extended 
beyond 28 weeks. Of these 30 pregnancies, 22 progressed to term, 7 termi- 
nated prematurely, and one woman at the time of this writing was 34 weeks 
pregnant. Patients vinder the care of private physicians and clinic patients 
received antenatal care that was no different from the care received by preg- 
nant women who had not had ligation of the inferior vena cava and ovarian 
vessels. 

The clinic patients who had had ligation received no more attention than 
other clinic patients. In fact, in their antenatal period they were checked by 
medical students, nurses, interns, or residents. In several instances, they 
neglected themselves. Some did not report for care until they had had 
abortions, vmtil their pregnancies were in the last trimester, or even until 
they were already in labor. These patients were on no special regimen of 
diet, drugs, exercises, or restriction of activity, nor were they instructed 
to wear special shoes, stockings, clothing, or supports of any kind. Some 
of the symiptoms and signs particularly sought were claudication, varices of 
the leg veins, vulvar veins, vaginal veins, hemorrhoids, dilated abdominal 
veins, or significant edema of the legs or vulva. Observations showed 



Medical News Letter, Vol. 33, No. 10 



no significant change from the normal. There were no instances of vulvar 
or vaginal varices. One patient who had varices of the lower extremities 
prior to ligation continued to have the same problena and one other patient 
had a postphlebitis syndrome. No problem of hemorrhoidal veins was des- 
cribed or recorded antenatally or during labor. There were a few record- 
ings of transient 1 plus edema, but in no instance was there significant 
persistent or progressive edema of the lower extremities. All patients con- 
tinued their former activities as domestics or housewives or both during and 
after their pregnancies except when specific problems of pregnancy per se 
necessitated hospitalization. 

Twenty-nine pregnancies were delivered and one patient was due to be 
delivered in September 1958, Twenty -four deliveries were vaginal. There 
were 5 cesarean sections. Labor and delivery in the private patients were 
not remarkable except that 4 of the 5 cesarean sections were in this group. 
In all but one instance, the clinic patients' labor was under the observation 
and guidance of medical students, interns, or in a few instances, residents. 
The exception was one woman who was delivered in a rural house unattended. 
Only the patients described under the heading of complications had any dif- 
ficulties in labor and delivery. These were the instances of antenatal bleed- 
ing and the case of pre -eclampsia in a private patient. The duration of labor 
was, in sonne instances, as short as 45 nriinutes and in one patient 14 hours. 
The conduct of labor was the same as for any other patient. 

No special techniques, no prophylactic antibiotics or anticoagulants 
were used nor was any special anesthesia insisted upon. In fact, several 
types of anesthesia were employed in the Z9 deliveries. Some patients had 
no anesthesia, others local, spinal, or general. The type of anesthesia was 
determined entirely by the obstetrical status and not by the patient's history 
of inferior vena cava ligation. The same obstetrical criteria determined the 
use of forceps and/or episiotomy. In no instance was delivery difficult. The 
third stage was notable in that in two instances manual removal of the pla- 
centa was necessary. 

There were 28 single births and one set of twins. Only 2 of the 30 babies 
did not survive. One patient was still pregnant. Twenty-two babies were con- 
sidered to be at term. One of these infants was stillborn. The mother had pre- 
eclampsia. Eight other infants, including the twins, were premature. One of 
these premature babies died after an unattended birth in a rural home. The 
heaviest term baby weighed 8 pounds, the smallest premature, 2 pounds. This 
infant survived. There was one fetal anomaly, bilateral talipes equinovarus 
and paraplegia. This child lived to the age of 2 years and died of sepsis and 
malnutrition. The paraplegia was not considered to be due to birth trauma. 
Studies at the cerebral palsy center did not disclose the cause and autopsy 
was not obtained. 

Pregnancy subsequent to ligation of the inferior vena cava and ovarian 
veins can proceed in a normal fashion. Interruption of the normal venous 



Medical News Letter, Vol. 33,- No. 10 



return from the human female reproductive organs does not influence any 
subsequent antenatal, intrapartal, or puerperal course. 

Pregnancy is not contraindicated after ligation of the inferior vena 
cava and ovarian veins. Special care is not necessary in managing the 
patients who subsequently conceive. (Collins, J. H. , Bosco, J. A. S. , 
Cohen, C. J. , Pregnancy Subsequent to Ligation of the Inferior Vena Cava ' 
and Ovarian Vessels: Am. J, Obst. & Gynec. , 77:760-769, April 1959) 

Asian Influenza A in Boston 
1957 - I95T 

In the city of Boston, the pandemic of Asian influenza A was acconn- 
panied by an estimated 118 fatalities from influenza and pneumonia in excess 
of the norm — approximately 38 of them during the first wave in October and 
November 1957, 42 in the second wave in March and April 1958, and the 
remainder in the intervening months. This report sunnmarizes the pertinent 
associated deaths in the Boston area with particular reference to problems 
of diagnosis and management. 

Each case was characterized by one or n-iore of the following criteria: 
(1) isolation of Asian influenza A virus from antemortem throat washings 
or postmortem tissues; (Z) tracheal, pulmonary, or myocardial pathology 
consistent with that previously described for influenza; (3) in the absence 
of previous immunization, significant levels of hemagglutination-inhibiting 
antibody against influenza A/Japan 305/57 strain and/or of influenza A com- 
plement-fixing antibody; (4) specific staining with fluorescein-labeled Asian 
influenza A antiserum. Three cases were included, although they did not 
meet the above criteria; each occurred at the height of the epidemic in the 
fall, presented classical clinical histories and findings of influenza at the 
onset of disease, and arose in families in which other cases of typical in- 
fluenza were occurring. This series of cases, therefore, reflects selection 
on the basis of diagnostic features, hospital admission, and performance of 
a postmortem examination; the series is also probably weighted with young 
adults. 

On the basis of ante -and postnnortem bacteriologic studies, the 3Z 
patients studied were separated into three groups: (a) influenza without bac- 
terial complication ("pure influenza")* 15 cases; (b) postinfluenzal staphylo- 
coccal pneumonia, 11 cases; and (c) postinfluenzal bacterial pneumonia 
nonstaphylococcal, 6 cases. Of the 32 patients, 21 had one or more chronic 
diseases of major proportions and 4 were pregnant women. Twelve patients 
including the 3 who died suddenly of nonpneumonic causes had advanced heart 
disease; 10 had either chronic intrinsic pulmonary disease or chronic respi- 
ratory insufficiency secondary to neurologic or neoplastic disease. 



10 Medical News Letter, Vol. 33, No, 10 



There were 18 males and 14 females in the series; pregnant women 
accoiinted for the preponderance (9:6) of women in the pure influenza deaths. 
Males predominated in the groups with postinfluenzal bacterial pneumonia 
and among the patients with no antecedent disease (6:2). 

Fatalities from both influenza and postinfluenzal bacterial pneunnonia 
occurred over a wide range of ages. Although the mean and nriedian ages of 
the patients with pure influenza were somewhat lower than those with bac- 
terial pneunnonia, these differences were not significant. 

The cases were characterized by a wide spectrum of modes of onset, 
symptoms and signs, laboratory findings, rates of progression, and modes 
of death. However, the many common features permit a general description 
of a typical fatal course. The onset of the disease in patients who died of 
pure influenza was characterized by a 6 to 12-hour prodronrie of malaise and 
fleeting myalgias followed by the appearance of fever, chills, headache, 
severe myalgia, pain on ocular movement, nasal congestion, mild sore 
throat, and prostration. Between the second and third days of disease there 
developed dyspnea, hemoptysis, and pleuritic chest pain. Tachycardia, 
tachypnea, and cyanosis then rapidly ensued with clinical findings of bilateral 
medium and coarse crepitant inspiratory rales usually involving two lobes 
and with roentgenographic evidence of involvement of two to three lobes. 
Both the white blood cell coxint and the percentage of polymorphonuclear 
neutrophils were usually either within normal limits or slightly elevated. 
The subsequent course was marked by rapid worsening of respiratory func- 
tion, intensification of the cyanosis, frothy hemoptysis and, terminally, shock 
and signs resembling those of pulmonary edema. Death most commonly 
occurred about the fourth day after onset of influenza, 24 to 48 hours after 
the onset of pneumonia, or 12 to 36 hours after severe disease was first 
clinically recognized. 

Analysis of these 32 cases reemphasizes several known facts concern- 
ing severe influenza and its complications, suggests the importance of some 
revisions in current approaches to the severe disease and its management, 
and underlines the pressing need for improved facilities for management of 
acute respiratory insufficiency. 

The data in this series confirni preepidennic predictions by public 
health authorities based on experience in previous epidemics: (1) Major 
population groups particularly susceptible to severe disease (and therefore 
prime candidates for immunization) were pregnant women and those with 
chronic heart disease and chronic respiratory insufficiency. (2) Influenzal 
and postinfluenzal pneumonias were the commonest and most severe com- 
plications. (3) Myocarditis was infrequent and generally minimal. (4) The 
occurrence of hemoptysis, tachypnea, and cyanosis in influenza — with or 
without prominent pulmonary findings — is highly indicative of potentially 
fatal disease. (5) Bacterial — particularly staphylococcal — pneumonia, 
when it occurs in adults following influenza, is generally more severe and 
more rapidly progressive than under other circumstances. 



Medical News Letter, Vol. 33, No. 10 11 



On the basis of experience with a wide variety of infectious diseases, 
most authorities have consistently opposed the haaty administration of anti- 
biotics prior to the effective clinical — or preferably bacteriologic — demon- 
stration of a specific pathogen and have particularly decried the indiscrimi- 
nate use of antibiotics in insusceptible virus infections. Implicit in these 
sound principles is the tacit assumption that there is enough time to make 
an accurate diagnosis. 

One is forced to the conclusion that in time of epidemic influenza, in 
localities in which major staphylococcal infections are known to be common, 
all cases presenting with signs of severe, potentially fatal influenza should 
be diagnosed and treated promptly as bacterial pneumonias — probably 
staphylococcal — until the diagnosis is proven otherwise. On the other hand, 
the data in this series lend no support to the practice of using "prophylactic" 
antibiotics in uncomplicated influenza. Indeed, as shown in the second ar- 
ticle of this series, they contradict it. 

The relative futility of standard vigorous supportive measures in pre- 
venting eventual asphyxia in the cases reported underscored the need both 
for a better understanding of pathogenetic mechanisms in fatal influenza and 
for a practical device which will function as an "artificial lung" — capable of 
efficient extrapulmonary gaseous exchange of oxygen and carbon dioxide — 
during periods of acute respiratory insufficiency. Such an apparatus is 
undergoing development in several laboratories. 

Although the data in the present series suggest that the administration 
of corticosteroids does not significantly alter the course of fatal influenza, 
the cases are too few in number and the controls too inadequate to state this 
point with assurance. {Martin, CM. , et al. , Asian Influenza A in Boston, 
1957 - 1958: A. M. A. Arch. Int. Med., 103: 515-531, April 1959) 

3j: ^ 9^ :^ 3[c :jc 

Pulmonary Abscess 

Pulmonary abscess has long been recognized as one of the most ser- 
ious diseases of the lungs and, prior to the availability of the antimicrobial 
agents, the prognosis was extremely poor both as to morbidity and mortality. 
With the advent of the sulfonamides, penicillin, and the other antimicrobial 
agents, and with the development of better techniques in the field of pulmon- 
ary surgery, the prognosis for these cases has greatly improved. 

This article presents a study of 70 consecutive cases of pulmonary 
abscess treated at the Veterans Administration Hospital, Louisville, Ky, , 
during the past 10 years. Abscesses resulting from tuberculosis, fungus, 
parasitic infection, and carcinoma constitute special categories and were 
purposely omitted from this study. All cases of pulmonary abscess in this 
series were referred to the Chest Therapy Board for evaluation and recom- 
mendations as to treatment. 



12 Medical News Letter, Vol. 33, No. 10 



The initial plan of management was to place the patient on bed rest 
and, after sputum specimens had been collected for culture, an antimicrob- 
ial agent was started. The preference of the Medical S. rvice was to start 
patients on penicillin alone, usually in a dosage of 100, 000 units of crystal- 
line penicillin every 3 hours, or 600, 000 units of procaine penicillin twice 
daily. This was not a fixed policy, however, and the responsible physician 
could use any antibiotic alone or in combination which he felt desirable, par- 
ticularly if the patient had received antibiotic therapy prior to admission. 
Subsequent antibiotic therapy was dictated by the clinical response and the 
results of bacteriologic determinations including sensitivity studies. Aux- 
iliary supportive measures which were employed as indicated were postural 
drainage, bronchodilator drugs, expectorants, blood transfusions, and a 
nutritious diet. Necessary procedures for the recognition and amelioration 
of coexisting pulmonary and systemic diseases were carried out. 

The response of the abscess to medical treatment determined whether 
surgical treatment was indicated. In general, surgery was believed to be 
indicated if the abscess persisted or if carcinoma was suspected. 

Of the 70 patients with pulmonary abscess, 59 were white and 11 were 
Negro. There was a uniform distribution in each 10-year period from 20 to 
60 years of age. Only 5. 7% were beyond 60 years of age. All were males. 

The duration of symptoms prior to admission varied from one month 
or less to 26 months. Thirty patients (42.8%) had had symptoms one month 
or less. Fifty-six patients (80%) had had symptoms 5 months or less. Five 
patients (7. 2%) had had no symptoms prior to admission. Three of these 5 
developed abscesses after admission to this hospital. 

Seven patients had severe oral sepsis, 5 had diabetes mellitus, 4 were 
chronic alcoholics, 3 had neurological disease, and 2 had cerebral arterial 
thrombosis. Fifteen patients had one each of the following disorders: post- 
ton sillectomy, thrombophlebitis, dorsal kyphosis, arteriosclerotic cardio- 
vascular disease, old chest injury, upper gastrointestinal hemorrhage of 
unknown cause, anxiety reaction, chronic pancreatitis, periarteritis nodosa, 
syphilis, lymphatic leukemia, cirrhosis, fracture, malnutrition, and cor- 
onary insufficiency. 

Forty-four patients were treated medically. As soon as the abscess 
was diagnosed, sputum was submitted to the laboratory for smear and cul- 
ture for predominating organisms and sensitivity determinations. An anti- 
biotic was commenced immediately without awaiting the results of the fore- 
going studies. The choice of an initial antibiotic varied and the selection 
was influenced by the preference of the ward physician and the consultant 
staff. In 21 patients, penicillin was used alone; in 12, penicillin plus a tetra- 
cycline drug was administered; in 3 patients, penicillin plus streptomycin 
was used; and in one patient, a tetracycline drug alone was used. In another 
single instance, because of the consideration of possible tuberculosis, strep- 
tomycin plus isonicotinic acid hydrazide was given. 



Medical News Letter, Vol. 33, No. 10 13 



The policy was that medical therapy be given to the patient with an un- 
complicated case to the point where no further improvement was considered 
probable. When carcinoma was suspected or when surgical complications 
existed, surgery was advised earlier. 

The proper use of antibiotics is essential to the effective management 
of pulmonary abscess. The studies emphasize the need for identification of 
the offending organisms at the onset of therapy and the need for subsequent 
studies of the sputum, preferably at weekly intervals, to detect the develop- 
ment of bacterial strains that are resistant to the antibiotic being employed. 
There were 4 patients whose original cultures grew FriedlUnder's bacilli. 
These organisms were not sensitive to penicillin. There were 2 patients in 
whom the initial cultures revealed both a streptococcus and Friedlander ' s 
bacilli and, with subsequent cultures, sensitivity determinations, and clinical 
correlation, the Friedlander' s bacillus was felt to be the offending organism. 
In 3 patients, hemolytic Staphylococcus aureus was not isolated initially but 
was subsequently cultured. This organism was resistant to penicillin. In all 
of the foregoing cases, the employment of an antibiotic to which the organisnn 
was sensitive was of vital importance. 

The selection of patients for surgery is an individual problem. The 
authors considered the indication for surgery to be the conclusive demonstra- 
tion that medical therapy had failed. They believe that nnedical therapy of only 
1 to 2 weeks is inadequate and that if any degree of improvement can be demon- 
strated, medical therapy should be continued. In addition, the authors believe 
that operation should be performed if the presence of carcinoma is suspected 
or if there exist or develop complications which are considered to be surgical, 
such as rupture of the abscess, empyema, bronchiectasis, or bronchostenosis. 

It is to be noted that 3 of the 4 patients who had a pneumonectonny died 
during surgery or in the imnaediate postoperative period. It has been stressed 
by other workers that this procedure for pulmonary abscess carries with it 
a high incidence of complications and a high mortality rate. 

The use of antibiotics and the development of better anesthesia and surg- 
ical techniques have substantially innproved the prognosis in pulmonary ab- 
scess. However, it still remains a serious problem. In this series, approx- 
imately 70% of the patients required hospitalization of from 1 to 4 months. 
In 20%, it exceeded 5 months. In 17. 1%, the disease terminated in death. 
Thus, in spite of medical progress, pulmonary abscess continues to be a 
prolonged morbid process with a substantial mortality rate. (Pickar, D. N. , 
Ruoff, W. F. , Pulmonary Abscess - A Study of 70 Cases: J. Thoracic Surg, , 
37: 452-459, April 1959) 

>^ ^^ ^ ^ ;|; :{: . 

Use of funds for printing this publication has been approved by the Director 
of the Bureau of the Budget, 19 June 1958. 



14 Medical News Letter, Vol. 33, No. 10 



Pulmonary Function in Bilateral Resection 

In recent years, bilateral pulmonary resection has become an accepted 
adjunctive form of treatment for pulmonary tuberculosis. Frequently, it is 
undertaken as an initially planned procedure in selected cases when definite 
indications exist and respiratory function is found to be adequate. In other 
cases, it is considered but not decided upon until the patient fully recovers 
from the first resection and pulmonary function is again carefully assessed. 
In connection with this latter group, it often becomes vitally important to 
obtain accurate information concerning the amount of remaining respiratory 
reserve. This applies also in certain complicated cases with already sig- 
nificantly impaired function in which resection on one side only might reduce 
respiratory reserve to a critical level. 

In addition to presurgical clinical assessment of the functional status 
of the individual, much help can often be derived from certain ventilatory 
tests when performed carefully and intelligently, using acceptable appara- 
tus. In borderline cases, this testing should include bronchospirometry as 
well as the more standard miethods of determining the total function. 

Changes in pulmonary function following unilateral resection for tuber- 
culosis have been studied and recorded by several investigators. It has been 
conclusively demonstrated that resection of diseased tuberculous segments, 
including lobectomy, often produces rather small, if any, reduction in pul- 
monary function in uncomplicated cases. 

Although bilateral resection for pulmonary tuberculosis has been em- 
ployed fairly extensively since 1953, there have been few published studies 
relating to pulmonary function changes. The present study was undertaken 
primarily to determine as accurately as possible the degree of change in 
pulmonary function following bilateral resection of varying extent. 

Twenty-nine patients who had had bilateral pulmonary resection of 
tuberculous lesions between Jvme 1955 and February 1958 were selected for 
study. This number was part of a group of more than 60 who had bilateral 
resections performed at the Nova Scotia Sanatorium since 1953, a review of 
which is to be published in the near future. Only the Z9 selected for this study 
had complete and identical ventilatory testing performed. All subjects had 
received previous bed rest and antimicrobial therapy for varying periods. 
Six had relaxation procedures performed at some time prior to surgery, two 
had had pneumothorax on one side a few years earlier, and four had pneumo- 
peritoneunn for at least a year. Li all cases, these procedures had been 
abandoned by the time of their first resection. None had a previous thoraco- 
plasty or phrenic nerve operation. 

Sixteen subjects were males; their ages ranged from 17 to 49 years 
with the majority in the 20 to 39 age group. 

Nineteen patients had tuberculous disease classified as moderately 
advanced at the time of admission. The disease to be resected was located 



Medical News Letter, Vol. 33, No. 10 15 



in the upper lobes, bilaterally, in all 29 patients. The indications for surg- 
ical intervention were residual fibrocaseous nodular disease, persisting 
cavitation, and bronchiectasis, or a combination of these types of disease. 
Disease known to be unstable and the presence of tubercle bacilli in the spu- 
tum influenced the decision regarding surgery in many instances. 

The extent of the operations varied considerably. A bilateral single - 
wedge resection was the combination in 10 patients. In 8 patients, one lobe 
and one wedge were resected; in 4 patients, one segment and one wedge were 
resected. A lobectomy with two segmental resections was perfornned in Z 
patients; a lobectomy with one segmental resection in 2 others. The remain- 
ing 3 patients had resection of: two segments and one wedge, one segment 
and two wedges, aind three wedges. The most extensive resections were a 
lobectomy on one side and two segments on the other performed on 2 patients. 
In all, 12 patients had lobectomies on one side. An "in-between" group of 7 
patients had one or two wedges resected on one side and either two wedges, 
two segments, one segment, or a segment and wedge on the other. The inter- 
val between operations varied from 10 weeks to 10 months with an average 
of 5 months. 

As determined by ventilatory tests employed, the reduction in pul- 
monary fiinction in this series of patients was small. The vital capacity 
decreased appreciably more in the major resection group (those having lobec- 
tomy) than in the minor, less extensive, resection groups. This finding dif- 
fers irom that of Taylor and associates who concluded that the vital capacity 
loss was remarkably similar in all of their one to seven- segment unilateral 
resection group. Only in their pneumionectomy group of 5 cases did they find 
a significantly greater loss than in lesser resections. 

Reduction in vital capacity was fairly constant for the minor resection 
groups and amounted for the median to 15% of actual and 14% of predicted 
values. In the major group of patients — those who had lobectomies on one 
side — the comparable figures were 21%, For the entire group, the median 
reduction was 18%. 

Maximal breathing capacity changes correlated to the extent of resec- 
tion better than did vital capacity, the reduction being in the vicinity of 17% 
of actual and 13% of predicted values in the major resection group. This 
contrasts with the results in the n:iinor resection groups which indicated no 
reduction. The median reduction for the entire group was 5%. 

The probable major cause for reduction of vital capacity is considered 
to be a thoracotonny effect which is of a restrictive nature. In the more 
extensive resections, pulnionary factors undoubtedly influence the results. 
On the contrary, maximal breathing capacity is apparently unaffected by the 
thoracotonniy factor when tests are performed several weeks after resection. 
The maximal breathing capacity test — although valuable — is not infal- 
lible because of the potential sources of error connected with its perform- 
ance. A correlation between other factors, including age, preexisting 



16 Medical News Letter, Vol. 33, No. 10 



conditions, and type of disease, with the group results could not be demon- 
strated. (Young R. C. , et al. , Pulmonary Function Changes in Bilateral 
Resection for Pulmonary Tuberculosis: Am. Rev. Tube re, , 79: 468-47Z, 
April 1959) 

ij: ;!«;{; si; :j: >Sc 

Laryngeal Trauma and Its Complications 



Laryngeal trauma with the complications of acute respiratory obstruc- 
tion may occur as an isolated injury or part of a multiple injury accident. 
Obstructing hematomas, dislocation, and fractures of laryngeal cartilage 
result from direct trauma of the neck in boxing, striking a protruding pipe 
or tree branch (or being struck by either), a blow from a baseball bat or 
golf ball, or falling while carrying a heavy object and striking its edge. 
Garroting or the entanglement of a scarf or necktie in machinery likewise 
produce collapse of the laryngeal cartilages. These cartilages maintain 
the patency of the airway and their destruction results in acute respiratory 
obstruction. Less severe injuries result in hoarseness, dysphonia, or 
aphonia. 

Automobile accidents are responsible for most of the multiple injury 
accidents in which the larynx is involved. The injury almost invariably occurs 
to the passenger in the front seat whose extended neck strikes the dashboard 
as the head is thrown forward through the windshield. The accident may occur 
to a passenger in the rear seat who is thrown forward against the back of the 
front seat, or to a street-car passenger whose neck strikes the pipe-like han- 
dle on the seat in front of him if the car stops suddenly or is involved in a 
head-on accident. A similar injury may occur to the pilot or copilot of a 
small plane in a rough or crash landing. For the passenger in the front seat 
of an automobile, some measure of protection is afforded by a safety belt and 
a heavy foam rubber pad over the dashboard; but while these suggestions are 
recommended by those attempting to reduce the morbidity and mortality from 
automobile accidents, few heed this advice. 

In this report, only cases of external trauma are reviewed. Cases of 
internal trauma, such as caustic burns of the larynx associated with the inges- 
tion of lye, surgical trauma, intubation injuries, feeding-tube accidents, paral- 
ysis of the larynx following thyroidectomy, and trauma due to vocal abuse 
are not included. 

An abnormal or absent voice following a history of trauma is fairly 
indicative of some degree of soft tissue or cartilaginous involvement of the 
larynx. A cerebral injury incurred in an accident could cause a voice change 
without direct laryngeal involvement; therefore, this possibility also must be 
considered. Voice changes maybe immediate and nrsay range from variations 



Medical News Letter, Vol. 33, No. 10 17 



in pitch and volume to total aphonia. Respiratory symptoms are progres- 
sive stridor, prolonged noisy inspiration and expiration, dyspnea, supra- 
and infra-sternal retractions and mental changes associated with acute or 
progressive chronic anoxemia. 

Palpation of the neck in suspected laryngeal trauma may disclose 
deformity, discoloration, abnormal movement or fixation of the thyroid or 
cricoid cartilages or the supporting thyrohyoid membrane. Commonly, in 
traumatic fractures of the larynx, the thyroid cartilage is flattened or one 
ala is found to overlap the other anteriorly. In recent injuries, crepitation 
and abnormal fixation and induration suggest deformity sufficient to cause 
stenosis. ■ 

X-Ray studies of the larynx — even in the infant — are of inestimable 
value when laryngeal trauma is suspected, not alone for diagnosis but for 
record and subsequent progress studies. Lateral x-ray studies of the neck 
for soft tissues often sxiffice, but in questionable cases or for more detailed 
study the anterioposterior intraesophageal film studies as well as planographic 
studies are indicated. The injection of opaque media such as lipiodol is occas- 
ionally helpful. Mirror and direct laryngoscopic photography provides a chron- 
ological record of treatment as well as a means of making "before and after" 
comparisons. 

Final evaluation of the general configuration, the location, degree, and 
extent of a laryngeal injury must be made by direct laryngoscopic and tracheo- 
scopic examinations. 

The therapy of laryngeal trauma must be guided by the extent of injury. 
If soft tissues alone are involved by an obstructing hematoma, voice rest 
(silence) and steam inhalations are essential. Low tracheostomy should be 
performed before it becomes a desperate emergency if obstruction is present 
on the initial examination of the patient or if dyspnea is becoming progressively 
more severe. Dysphagia will undoubtedly be a complication in this type of 
trauma, but the use of a feeding tube is to be avoided because of the ulcera- 
tion that it may cause in the mucosa of the laryngopharynx. 

Severe compressing injuries, such as acute injuries to the larynx result- 
ing from automobile accidents, require as active a therapeutic regimen as 
would be employed in a crushing injury of the nose. Broken cartilages must 
be replaced, the airway reestablished, and a splint must be introduced to 
maintain the position of the replaced cartilages until healing is effected. Emer- 
gency tracheotomy is life-saving when the accident has occurred and the 
compressed laryngeal structures occlude the airway. It is extremely impor- 
tant that the tracheotomy be placed low, as far from the fractured larynx 
as possible, to avoid loss of the cricoid through further trauma and infection. 

The active measures that should be undertaken early should restore 
and maintain the fractured cartilages as close to their original position as 
possible, and as soon after the accident as is permitted by the general 
condition of the patient. Peroral manipulation with forceps or the tip of 



18 Medical News Letter, Vol. 33, No. 10 



a laryngoscope may suffice in some cases to reestablish the airway. In other 
cases, immediate open reduction may be required to obtain satisfactory re- 
alignment of cartilages. Following either procedure, a polyethylene or sim- 
ilar tube may be inserted into the glottis to serve as a splint to support the 
soft tissues until healing takes place. 

It is unfortunate that often in a multiple injury accident in which the 
laryngeal fracture seems but a minor or unimportant complication, after the 
airway has been satisfactorily established by the tracheotomy, the larynx is 
left untreated. Often, the associated jaw and sternal fractures, internal 
injuries, and fractures of the extremities take precedence in therapeutic 
importance. The larynx is xindersteindably difficult to reach under these cir- 
cumstsmces. 

Nevertheless, it is essential that fracture -reducing procedures be in- 
stituted within the first few days following the accident before the cartilages 
have become fixed in their compressed obstructing position, and before scar 
tissue forms in the accompanying hematoma to further contract, or even 
completely obliterate, the airway. These procedures are too often delayed 
in the hope that as swelling subsides the airway will return to an adequate 
size. This does not occur unless the trauma has been minimal and is un- 
accompanied by fracture dislocation of the cartilaginous framework of the 
larynx. 

Severe laryngeal trauma that is not treated by early replacement and 
fixation of fractured or dislocated cartilages progresses to chronic laryn- 
geal stenosis with a distressing degree of disability. Physical impairment 
ranges from respiratory effort, stridor, and even chronic anoxemia, to 
actual acute obstruction which may have to be relieved mechanically by 
tracheotomy. 

Mentally, the disability is aggravated by the annoyance of the tracheo- 
tomy tube and the psychic stress of am abnormal, peculiar voice which is 
a constant source of embarrassment. This continues far beyond the first 
contact with others. Children so afflicted are subject to teasing and insults 
from their playmates, and adults have difficulty not only socially, but in 
finding or keeping steady employment. 

Failure or inadequate early management results in chronic laryngeal 
stenosis and the need of a permanent tracheostomy. Treatment of this com- 
plication requires reconstruction of the laryngeal lumen through the removal 
of scar and deformed cartilage and the lining of the interior of the larynx 
with a split thickness skin graft. This long and tedious process can be avoid- 
ed by early reduction and fixation of the laryngeal fractures. (Holinger, P. H. , 
Johnston, K. C. , Laryngeal Trauma audits Complications: Am. J. Surg., 
97^: 513-517, April 1959} 

*r T^ *r 'r n^ ^r 



Medical News Letter, Vol. 33, No. 10 19 



Chelating Agents in the Therapy 
of Beryllium Poisoning 

Piieumonoconiosis associated with heavy-metal inhalation has long 
resisted most forms of therapy. The development of chelating agents offers 
a new approach to this problem. This report concerns efforts to study the' 
effect of ethylenediamine tetra-acetic acid (EDTA) on the urinary excretion 
of beryllium in two patients with beryllium pneumonoconiosis. After beryl- 
liun:i pneumonoconiosis had been proved in these cases by lung biopsy, a trial 
of chelation therapy was suggested as a useful adjuvant in the treatment of 
this disease. 

EDTA, a polyamino carboxylic acid, forms water-soluble, relatively 
unionizing chelates with polyvalent cations and has been shown to cause 
nnarked increases in the excretion of the heavy nnetals without the usual 
toxicity associated with reaction of the metal ion with body tissues. EDTA 
has found special usefulness recently in the treatment of lead intoxication 
and cadmium poisoning. 

The amount of beryllium that can cause histologically observable tis- 
sue damage is less than 0.01 nriicrogin. per gram of tissue. Currently, 
there are two suggested theories of the nnechanisnn of granuloma formation 
leading to the pulmonary disability and eventual cor pulmonale seen in this 
disease. Sterner and Eisenbud cite the theory that the metal ion combines 
with tissue protein to form an antigenic substance that is then fixed to tissue. 
The gradual release of antigen from the body stores then elicits the granulo- 
matous reaction. Schubert and White suggest that the granuloma results 
from the oligodynamic action of traces of solubilized beryllium that diffuse 
from the periphery of the nrietal particle. The limited success of steroid 
therapy lends support to the former theory because the action of a steroid 
in minimizing antigen-antibody reactions as well as its effect on fibrous 
tissue is well known. The demonstration of a specific skin sensitivity to 
beryllium patch tests also favors the view that an acquired allergy may be 
involved. 

In the present study, removal of the toxic nnetal was attempted by the 
use of a chelating agent that might be expected to form a soluble and diffus- 
able complex. Histochemical studies have shown that complex-forming 
reactions take place even when beryllium is bound to tissue protein for long 
periods. The use of ACTH or the steroids to help break down the granulo- 
matous reaction surrounding the metal particle, thereby exposing the metal 
to the action of the therapeutic agent, has been suggested. It is believed 
that if a significant lowering of the body stores of beryllium can be effected, 
the clinical course of the disease may be favorably influenced. 

Chelation is the name given to the reaction between a polyvalent metal 
ion and a suitable compound (ligand) to form single or multiple internal -ring 
structures incorporating the metal ion. There is a definite order of strength 



20 Medical News Letter, Vol. 33» No. 10 



of chelation, somewhat analogous to the electromotive series of the various 
metals, dependent in part on the formation constants (log K) with the ligand 
involved. A metal of higher log K can be expected to displace one with a 
lower log K from its chelate. 

The agent selected for this study was the trisodium salt of ethylene - 
diamine tetra-acetic acid, "When EDTA is introduced into the body as a free 
acid or as the trisodium salt, it will bind the calcium ion, owing to the high 
log K of calcium and ready availability of this circulating metal in ionized 
form. In fact, if the administration is rapid and the concentration of the 
agent is high enough, serum calcium concentration falls and hypocalcemic 
tetany may result. For this reason, the drug is usually administered as 
the calcium salt. Several comprehensive discussions of the properties, uses, 
toxicity, and pharmacologic action of chelating agents in general and EDTA 
in particular have recently appeared in the literature. 

Side effects were minimal in this study. The single occurrence of hypo- 
calcemic tetany was directly related to excessive speed of ad niiini strati on. 
Patients occasionally complained of mild discomfort along the course of the 
vein used for infusion. This could be avoided or abated by slowing the drip. 
No such problems were encovmtered when calcium EDTA was used. Exam- 
inations of daily samples of urine failed to give any signs of renal damage, 
and blood chemical studies were negative except for one serum calcium deter- 
mination during the hypocalcemic incident which showed a calcium level of 
6. Z mg. per 100 ml. The administration of calcium gluconate during the epi- 
sode of hypocalcemia apparently did not affect beryllium excretion. The slight 
diuresis noted during therapy may be ascribed to coincidental chelation of zinc in 
the kidney regulatory mechanisms with subsequent inhibition of carbonic anhydrase. 

The results indicate that trisodium EDTA or calcium EDTA will enhance 
the urinary excretion of beryllium. The calcium salt appears to be the drug of 
choice. Whether this metal is being removed from the lung or from some other 
tissue store has not been determiined. Also to be investigated is the possibility 
that the sequestration of other trace metals will affect the beryllium excretion. 

Emphysema and diffuse fibrosis are presumably much more important 
than the granulomas fron] the standpoint of symptomatology, but it is suggested 
that long-term, intermittent therapy with a chelating agent such as EDTA may 
so deplete the body stores of beryllium ion that the clinical course or progress 
of the disease may be favorably affected. Some idea of the amount of calcium 
EDTA that maybe required to remove significant amounts of beryllium from 
the body to achieve this goal may be gathered from Dutra's observation that 
the beryllium content in cases of chronic beryllium pneumonoconiosis ranged 
from 0. 93 to 78.0 microgm. per 100 gnn. of lung tissue. Still to be investigat- 
ed are the side effects of EDTA therapy on the body stores of trace metals, 
many of which are of extreme importance in enzymatic and metabolic reac- 
tions. (Cash, R. , et al. , Chelating Agents in the Therapy of Beryllium Poisoning: 
New England J, Med., 260:683-686, April 2, 1959) — 



Medical News Letter, Vol. 33, No. 10 21 



From the Note Book 

1. RADM Lamont Pugh MC USN (Ret), a former Surgeon General of the 
Navy, has written his autobiography in a new book entitled, "Navy Surgeon, " 
and released about April 29, 1959 by J. B. Lippincott Co, , of Philadelphia. 
Rear Admiral Pugh served as Surgeon General of the Navy from February 
1951 to February 1955, He retired from active service on August 1, 1956. 

'Navy Surgeon, " an unmistakably American story, is more than an autobio- 
graphy — it is a record of recent history told by a man who has lived it. 

(TIO, BuMed) 

2. Five articles on aviation medicine subjects are featured in Naval Aviation 
News, May 1959. The articles are: Johnsville High G Study; Navy Flight 
Surgeons' Exhibit; Project Mercury Astronauts; Meet a Mach Medic: and 
Ranger Men Try Their New Suits. (AvMedDiv, BuMed) 

3. U. S. Naval Medical Research Unit No. 3 in Cairo was represented at 
the Ninth Middle East Medical Assembly at the Anrierican University at 
Beirut, Lebanon by four members of the Unit presenting scientific articles. 
LT T. G. Akers,MSG USN presented a paper entitled, "Poliomyelitis in 
Cairo, Egypt, U. A. R. , during 1958 -age, season, and poliovirus distribution 
of 447 confirmed cases of paralytic poliomyelitis. " LT N. L. Freeman MSC 
USN presented a paper entitled "Hemagglutination Studies with Schistosoma 
Hematobium Antigens. " 

A scientific exhibit entitled, "The Treatment of Shigellosis with Furoxone, " 
was monitored by LTCDR M, E. Musgrave MC USN. CDR R. E. Fultz MC USN 
attended the Assembly as official delegate of NAMRU-3. LCDR K. C. Hoerman 
DC USN presented a scientific paper before the naeeting of the International 
Association of Dental Research, British Division, Manchester, England, en- 
titled, "Research Studies Concerned with Protein Components in Parotid Gland- 
ular Secretion. " (NAMRU-3) 

4. U. S. Navy and Public Health Service scientists have reported that a 
commercially prepared vaccine has proved 83% effective in preventing Asian 
influenza among a group of Naval recruits. Results of the carefully planned 
study at the Great Lakes Naval Training Station also revealed that a multi- 
strain vaccine used earlier by the nnilitary — one not containing the Asian 
strain — also provided a modified degree of protection against the Asian type 
of influenza. (PHS, HEW) 

5. Injuries to the hand from homemade rockets are becoming more frequent. 
The first procedure is extremely important. The surgeon is aided in the 
treatnnent of these particular injuries by the young age of the patient, with 
his excellent recuperative powers and remarkable capacity for compensating 



22 Medical News Letter, Vol. 33, No. 10 



and adapting to disability. (Am. J. Surg., April 1959; F. A. Arcari, M. D. , 
R.D. Larsen, M. D. , J. L,. Posch, M. D. ) 

6. This report presents and compares the findings, clinical course, and 
management in 1 1 fatal cases and 9 nonfatal cases of post-Asian influenzal 
staphylococcal pneumonia occurring in Boston and environs. The report 
analyzes the properties of the strains of staphylococci responsible, and 
demonstrates the importance of the rapid choice of effective antistaphylo- 
coccal chemotherapeutic agents. (A. M. A. Arch. Int. Med., April 1959; 
C. M. Martin, M. D. , et al. ) Note article, "Asian Influenza A - Boston 
1957 - 1958", page 9. 

7. Seven years' experience with various types of resections for pulmonary 
tuberculosis is reviewed. By judicious use of procedures described, a 
maxinr^um amount of functional tissue can be preserved. The simplest bron- 
chial closure yields excellent results. There is no evidence that preresection 
thoracoplasty is of value. (J. Thoracic Surg., April 1959; D. V. Pecora, M. D. ) 

8. The results of the lung function tests on 417 patients with pulmonary tuber- 
culosis presented for possible thoracic surgery, are reviewed. A brief prac- 
tical routine for presurgical evaluation is described. (Am. Rev. Tuberc,, 
April 1959; J.W. Morton, 1 Khan) 

9. Cancer of the large intestine (including the rectum) is the most common 
malignancy that occurs in men and the 3rd most common in women. It 
accounts for 33, 000 annual cancer deaths in the U. S, Men are affected al- 
most twice as frequently as women and the average age of occurrence is 
between 50 and 70. (G P, April 1959; E. M. Miller, M. D. ) 

10. This article discusses the higher fetal nnortality with repeat abdominal 
delivery, its relation to prematurity, and measures that may be used to 
improve the situation. (Am. J. Obst. feGynec. , April 1959; A. W. Diddle, M. D. , 
V. Gibbs, M. D. , S, Lambeth, M. D. ) 

11. This study reports the pattern of solute and water excretion in mercurial 
diuresis in patients with congestive heart failure and relates the findings to 
those obtained in normal human subjects. (Circulation, April 1959; N. Spritz, 
M. D. , et al. ) 

12. Smallpox vaccination is important for everyone in this country. Vaccination 
is especially urgent for all persons planning foreign travel, for those who pro- 
vide services in international travel and commerce, and for personnel in hos- 
pitals and health services. (PHS, HEW) 

^ ;^ ^ >^ :}: :{c 



Medical News Letter, Vol. 33, No. 10 23 



American Board of Obstetrics and Gynecology 

"Office of the Secretary: Robert L. Faulkner, M. D. 

2105 Adelbert Road 
Cleveland 6, Ohio 

Applications for certification (American Board of Obstetrics and Gyne- 
cology), new and reopened. Part I, and requests for re -examination Part 11 
are now being accepted. All candidates are urged to naake such application 
at the earliest possible date. Deadline date for receipt of applications is 
August 1, 1959. No applications can be accepted after that date. 

Candidates are requested to write to the office of the Secretary for a 
current Bulletin if they have not done so in order that they might be well 
informed as to the present requirements. Application fee ($35.00), photo- 
graphs, and lists of hospital admissions must accomipany all applications, " 

9}: ^ :^ 4: :^ ^ 

Shipboard Pest Control - 

A New Training Film 

The Bureau of Medicine and Surgery announces the release of a new 
training film entitled "Shipboard Pest Control" (MN-8722) which will be of 
interest alike to medical and line personnel who are in any way concerned 
with this critical aspect of preventive medicine. The film presents the three 
essential points of an effective pest-control program: prevention of entry, 
destruction of such pests as are already aboard, and good housekeeping to 
prevent breeding of pests in shipboard spaces. 

The picture summarizes methods of pest destruction and reviews in 
general the important considerations in fumigating, trapping, poisoning, and 
dusting. It then presents in detail the principles and techniques of space spray- 
ing and residual spraying as applied against appropriate pests in specific loca- 
tions. Throughout the film, precautions are emphasized for the safety of per- 
sonnel engaged in the work of extermination. 

Although this film was planned for use aboard ship and by the Navy's 
Preventive Medicine Units in their work with the Fleet, its subject matter 
will have equally useful application at shore stations. Personnel concerned 
with environmental sanitation in hospitals, barracks, messing facilities and 
the like may be interested in adopting it for use in their training programs. 

Prints are being distributed to District Training Aids Sections and 
Libraries, and selected key stations. If prints are not available from your 
usual source, address inquiry to the Film Distribution Unit, Training Division, 
Bureau of Naval Personnel, Department of the Navy, Washington 25, D. C, 

(Audiovisual Br. , BuMed) 



24 Medical News Letter, Vol. 33, No. 10 




DEI\TAL SIkW^I section 



Dental Cutting Procedures 

Investigation of the fundamental physical operating characteristics of 
rotary dental cutting devices is being conducted in the Dental Research Sec- 
tion of the National Bureau of Standards. The formation of any new surface 
area (as in the chip formation associated with cavity or crown preparation) 
requires a certain amount of energy. All dental handpieces and all rotary 
cutting instruments represent nnerely a means of transferring this energy 
from a source of power (dental engine, air compressor, hydraulic pump, 
et cetera) to the surface of the tooth. However, in the process of energy 
transfer certain losses occur. Some of these losses (belt drag, wind resis- 
tance, bearing friction, gas of fluid viscosity) serve only to raise the total 
energy consumed eind as long as they are held to any reasonable value may 
be disregarded. Other losses, however, which result in the dissipation of 
portions of the energy as heat are of prime biological importance. 

In this study the total energy transferred to the cutting instrument by 
the handpiece, the portion of this energy going into useful cutting, and the 
portion going into heat production are being measured and their relationships 
are being studied as a function of instrument speed, instrument design, in- 
strument wear, et cetera. 

The total energy transferred to the cutting instrument by the hand- 
piece is determined by the simultaneous measurement of speed and torque. 
This is accomplished in either of two testing machines which have been 
designed and constructed specifically for this purpose. One apparatus which 
is used for low speed, high torque handpieces (most belt driven types) em- 
ploys an eddy current brake for torque measurenrient and a photo-electric 
system for speed determination. The second apparatus used for high speed, 
low torque handpieces (most turbine types) makes use of a synchronous elec- 
tromagnetic field principle for torque raeasurenient and an electronic system 
for simultaneous speed determination. 

The amount of energy going into useful work is expressed in terms of 
the amount of material removed during unit time intervals. The amount of 
energy going into heat production is measured in a specially designed micro- 
calorimeter. At present, only specinriens of a standard "half-hard" brass 
(which closely simulates dentin with respect to cutting characteristics) have 
been ennployed; however, the use of other materials is contemplated. 



Medical News Letter, Vol. 33, No. 10 25 



Preliminary results indicate that when cylindrical carbide burs are 
used the ratio of the anriount of energy going into cutting to the amount going 
into heat production becomes significantly greater when a rotary speed of 
about 100, 000 rpm is reached. The ratio continues to improve through the 
highest rotary speeds tested (350,000 rpm); however, the amount of improve- 
ment is not great above the 100, 000 rpm range. (Perkins, R. R. , Taylor, D. F. . 
Kumpula, J. W. , Evaluation of Dental Cutting Procedure: National Bureau of 
Standards Progress Report #6326, December 31, 1958) 

:jc »}: :^ :{: :J: :{: 

Dentist -Population Ratios 

According to Dr. J. Stork of the Netherlands, officer of the Federation 
Dentaire International, the ratio of dentists to population varies greatly 
throughout the world, A favorable ratio of 1 per 1600 exists in West Germany 
while the astonishing ratio of 1 per 1, 750,000 exists in Arabia (Yemen). In 
the United States, there is a ratio of one active dentist for each 1900 population. 

^ 4: ^ ^ ^ >!t 

American Academy of Oral Pathology 
Elects New Officers 

Two Navy Dental Corps officers have been elected for office in the 
American Academy of Oral Pathology for the year 1959-1960. Captain 
Robert A. Colby DC USN, on duty at the U. S. Naval Dental Clinic, Yokosuka, 
Japan, was elected President Elect; Commander Henry H. Scofield, Jr. , 
DC USN, on the staff of the U S. Naval Dental School, National Naval Medical 
Center, Bethesda, Md. , was elected Vice President. 

>[c * * il: * * 

Board Certifications 

Five DC officers recently received American Board certifications. 
Captain Paul W. Suitor DC USN, Administrative Command, NTC, San Diego, 
Calif; and Captain Frederick T. Wigand DC USN, U, S. N. H. , Jacksonville, 
Fla. , were certified Diplomates of the American Board of Oral Surgery. 

Certified as Diplomates of the American Board of Periodontology were: 
Captain Alfred L. Raphael DC USN, Naval Dispensary, Washington, D. C. ; 
LtCdr Perry C. Alexander DC USN, staff of Naval Dental School, NNMC, 
Bethesda, Md. ; and LtCdr Oscar W. Donnenfeld DC USN, U. S. Naval Station 
Newport, R. I. 

i^i >fi: i(i ij: sfi ^ 



26 Medical News Letter, Vol. 33, No. 10 




RESERVE SECTION 



Two Weeks' Course in Military Entomology 

The Armed Forces Pest Control Board will conduct a 14-day training 
course in Military Entomology under the auspices of the Naval Medical 
School, National Naval Medical Center, Bethesda, Md. , 3-16 August 1959. 
This annual course, given for the first time in July 1958, has the following 
main objectives: 

1. To provide advanced training in military entomology for active duty 
and Reserve entomologists of the military services. 

Z. To make known to nonmilitary individuals and organizations the 
contributions which the military services have made and are making to 
the science of entonaology and the control of arthropod pests and vectors. 

3. To indicate the nature of the entomological problems which con- 
front the Armed Forces and to stimulate scientific research in basic and 
applied problems which required attention, 

4. To develop a continuing sympathetic and cooperative attitude toward 
military entomology on the part of universities and other civilian organ- 
izations. 

Eligible inactive Reserve Medical Service Corps officers whose specialty 
is entomology of both pay and nonpay programs of the Naval Reserve may re- 
quest this training. Quotas will be allocated to the Third, Fourth, Fifth, Sixth, 
and Ninth Naval Districts. The course will be limited to 30 attendees. There- 
fore, applications should be forwarded as soon as possible to the Commandant 
of the appropriate Naval District. Messing and linnited B, O. Q. facilities at 
the National Naval Medical Center are available. Minimun} uniforms for a 
Z-week period are necessary. Security clearance is not required. 

Applicants anticipating attendance should notify, prior to 30 June 1959, 
the Preventive Medicine Division, Bureau of Medicine and Surgery, Potomac 
Annex, U, S. Department of the Navy, Washington Z5, D. C. 

rfi rfe j}g sj c ife A 

Naval Reserve Medal 

The Secretary of the Navy on 12 September 1938 established the Naval 
Reserve Medal to be issued by the Chief of Naval Personnel to officers and 



Medical News Letter, Vol. 33, No. 10 27 



enlisted personnel of the Naval Reserve who have completed 10 full years of 
satisfactory Federal service as defined by Public Law 810, 80th Congress, 
as annended. 

Service in the Marine Corps Reserve may be counted towards estab- 
lishing eligibility for the Naval Reserve Medal if the applicant has been 
appointed or enlisted in the Naval Reserve within 3 months of separation from 
the Marine Corps Reserve, and provided that such Reservist has not been 
awarded a Marine Corps Reserve Medal based on any portion of the time in- 
cluded in his application for the Naval Reserve Medal. 

For each additional 10 years of qualifying service, the Chief of Naval 
Personnel will on request authorize the wearing of a bronze star on the 
ribbon. 

All honorable service, active or inactive, as a member of the Naval 
Reserve prior to 1 July 1950 maybe counted for qualifying purposes. 

After 30 June 1950, in order to achieve a year of satisfactory Federal 
service for the Naval Reserve Medal, as defined in Public Law 810, 80th 
Congress, as amended, a Naval Reservist must accumulate during each 
anniversary year a total of 50 retirement points. An anniversary year com- 
mences on 1 July and ends the following 30 June. 

Credit may be accrued toward the Naval Reserve Medal on either active 
or inactive duty, and the required 10 years need not be continuous. Service 
in a regular component of the Armed Forces shall not be creditable. Service 
on either the Honorary Retired List of the Naval and Marine Corps Reserve 
or the Inactive -Status List shall not be deemed to be Federal service for this 
purpose. 

The Naval Reserve Medal will not be awarded for any service after 
12 September 1958. (The Arnned Forces Reserve Medal will be awarded to 
any officer or enlisted member or former member of the Reserve component 
who completes or has completed a total of 10 years of honorable satisfactory 
service after 12 September 1958. ) 

Applications should be submitted in letter form to the Chief of Naval 
Personnel via commanding officers or Naval District Commandants as appro- 
priate. 

Change of Address 

Please forward requests for change of address for the News Letter to: 
Comnnanding Officer, U. S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. , giving full name, rank, corps, and old and new 
addresses, 

^ ;{: sj: ^ >^ :§: 



28 Medical News Letter, Vol. 33, No. 10 



PREVE]\TIVE JUEDICIJVE SECT101\ 



Preventive Medicine in Infectious 
and Noninfectious Diseases 

Over the centuries, epidemic diseases have tended to wax and wane, 
to change their form and sometimes their character as one type of infection 
disappeared and another achieved prominence, to become resurgent without 
apparent reason and equally mysteriously to decline. This periodicity which 
has been the classic attribute of the acute infections rennains a mystery, but 
nevertheless, thought, study, and reason have enabled empiric remedies to 
be applied on a commiinity basis. Whether the method was specific and con- 
cerned the handle of the Broad Street pump or resulted from the philosophy 
of Jeremy Bentham of "the greatest happiness of the greatest number, " each 
of these n^en of history working in the darkness of scant scientific Icnowledge 
was able to make a contribution to the prevention of disease and the allevia- 
tion of suffering. 

In the realm of infectious disease or of noninfectious illness, the nat- 
ural history of the condition can be studied from the original forces which led 
to its occurrence and the alterations brought about by the disease process to 
its eventual termination either through return to the normal or by partial or 
total destruction. Every case of an individual disease does not conform to 
the classic conception which describes the inain features in synnptomatology; 
epidennics vary in their pattern. Throughout the process, the natural history 
may undergo change in the individual by the entry of some new factor so that 
variation from the typical nnay occur; similarly, in the community, alteration 
nnay take place in the pattern of epidemic or mass disease by the interposition 
of an accidental or deliberate change in conditions applicable to the normal 
development of the natural process. 

Through a careful study of the processes of disease, it may be possible 
to formulate plajis based on knowledge of the natural history and of the appro- 
priate points in the innate process of the disease at which control nneasures 
may be applied. This is particularly true of infectious diseases and has been 
demonstrated by alterations in the pattern of epidemic disease through the 
effect of changes in environmental and sociological factors and by the applica- 
tion of specific biological measures of control. Thus, sonne of the great epi- 
demic infections of the past have been submitted to control and eventual era- 
dication by improvements in sanitation and living conditions, while specific 
prophylactic measures have wrought changes in the pattern of diseases like 
smallpox and, in more recent times, diphtheria, and are already causing 
alterations in the pattern and age incidence of poliomyelitis. 



Medical News Letter, Vol. 33, No. 10 29 



In the western world where acute infections no longer loom as a major 
epidemiological problem, the time is more than ripe for intensive study of 
disease processes in other fields than those of the infective illnesses. The 
scope of the epidemiological method must now be widened to include mass 
disease or trauma, and there is no reason to suppose that a combination of 
intensive epidemiological study combined with application of public health 
methods is incapable of making a great in:ipact on many conditions which have 
now emerged as urgent public health problems causing major morbidity and 
mortality. 

The group of diseases included under the generic title of cancer is grad- 
ually proving itself amenable to successful epidemiological study and statisti- 
cal analysis as to cause and effect. In the industrial field, the eradication of 
certain types of cancer has already been achieved and — by the statistical 
method — researchers have pointed the way towards possible control measures 
in cancer of the lung and bronchus. Deaths from leukenriia continue to show an 
increase and most authorities believe the increase is not wholly explicable on 
the grounds of better understanding of the disease or to improved facilities 
for making the diagnosis, but is due to a real increase in incidence. The con- 
nection between ionizing radiations and leukemia has undergone study on a 
nation-wide basis; results have been published of a study on the histories of 
children certified to have died of malignant disease. In respect to children 
dying fronn leukemia and other fornns of malignant disease, nearly twice as 
many of the mothers said they had been subjected to x-ray examinations of the 
abdomen during pregnancy as did the mothers of the control children. A sim- 
ilar excess was not found when studies were made of the mothers before con- 
ception or of the children after birth. If the implications of this investigation 
are confirmed, an effect may be expected on clinical practice and on the inci- 
dence of leukemia and other forms of malignant rlisease in children. These 
examples are sufficient to illustrate the importance of epidemiological, sta- 
tistical, and sociological study of this group of diseases which ranks next to 
diseases of the heart and circulatory system as the greatest cause of mor- 
tality. 

The increase in coronary disease in recent years has resulted in inten- 
sive study by the research worker in collaboration with the clinician into the 
underlying causes of the changes leading to coronary atherosclerosis. In 
laboratories and hospitals, extensive research into the basic underlying causes 
of this condition and its treatment is being tindertaken by individuals or groups 
of workers. The volume and nature of this research La the laboratory and 
hospital are not matched, however, by epidemiological or sociological inves- 
tig;ation. Because factors related to diet, nutrition, exercise, social class, 
occupation, and stress — as well as genetic factors — may have important im- 
plications in the etiology of this condition, it would seem to be susceptible to 
useful investigation on epidemiological lines. The Social Medicine Research 
Unit of the Medical Research Council has undertaken studies of coronary 



30 Medical News letter. Vol. 33, No. 10 



atherosclerosis and. ischemic heart disease in relation to social class and 
nature of work. A group from the Social Medicine Departnnent, University 
of Birmingham, Warwick, England, have carried out a survey of patients 
suffering from coronary-artery disease with special reference to raised "., 
blood pressure, smoking habits, ajid mental stress in ennployment. Some 
medical officers of health are carrying out investigations into environmental 
and social conditions in coronary disease in collaboration with hospital clin- 
icians and family doctors, but there is scope for extension of such work by 
coordinated effort on the part of the epidemiologist, the health worker, and 
the clinician. 

Other mass diseases which are causes of high morbidity or nnortality — 
bronchitis, a major cause of invalidism and death; chronic rheumatism, a 
prime cause of loss of working capacity; mental illness, an outstanding com- 
munity health problem; and many other disorders of high incidence — are 
worthy of intensive epidemiological study and evaluation of the ecological 
influences in their origin and progress. 

In the measurement of the effect of disease upon the connmunity, it is 
necessary to have reasonably accurate information which normally comes 
from mortality statistics, although these may not provide a true picture of 
morbidity or the actual amount of current sickness prevalent in a commvmity. 
Therefore, to pave the way for fruitful epidemiological investigation and 
subsequent administrative action for prevention, control, or alleviation, 
reliable data are essential not only of death rates but of morbidity. This is 
particularly the case if epidemiological investigation is to be applied to high 
incidence or mass diseases of a noninfective character. Much more attention 
has recently been paid to the collection of such information, a fruitful source 
of which is the family doctor. The establishment of registration schemes for 
the collection of information ibout cancer will in time afford valuable clinical 
information as to diagnosis, therapy, and prognosis, and will also provide 
data on which to base the education of the public and the medical profession 
on its sociological, psychological, and epidemiological aspects. 

Use of the experimental method in research is accompanied by frequent 
failure to achieve the objective, by partial success in obtaining new knowledge, 
and by continuing experiment in the same or allied fields. The pursuit of know- 
ledge through epidemiological methods equally must have its failures and no 
sound investigation is worthless because of lack of success in new discovery. 
The real failure will lie in neglect to seize the opportunities which are pre- 
senting themselves to every health authority, health worker, and to every 
epidemiologist. The compilation of information, study of mass disease, and 
the application of sound administrative methods can produce effects as pro- 
found as those which eradicated the epidemic diseases. Failure is the grave- 
yard of lost opportunities. (Sir Kenneth Cowan, Presidential Address to 
Preventive Medicine Section, Health Congress, Eastbourne, Sussex, England, 
Roy. Soc. Promot. Health J. ,78: 530-532, September - October 1958) 



Medical News Letter, Vol. 33, No. 10 31 



Salmonella Infections in Children's Wards 

Cases of Salmonella infection arise from time to time without cause 
or connection with other incidents. The author finds that the periodic exam- 
ination of feces from children in a ward is of value not only to obtain an early 
diagnosis, but also to prevent cross -infection. In the outbreak described, 
only 3 cases were clinically apparent, but the infection was kept going for 
2-1/2 months by 10 symptomless excreters among patients and staff. The 
symiptomless excreters were detected only because the feces of every child 
in the ward were exaniined on admission and once every week thereafter. 

Two children were still excreting Salmonella 10 months after they were 
first infected. (Jellard, C.H. , et al. An Outbreak of S. Bovis-Morbificans 
Infection in a Children's Ward: Lancet, U 390-392, 21 February 1959) 

ste A A ?Jc sfc sjlc 

Selected Materials on Staphylococcal Disease 

The staphylococcus has been recognized for many years as an innpor- 
tant organism associated most often with suppurative processes of man and 
animal. Staphylococci are found in man and in the immediate environment 
of man so frequently that staphylococcal infections must be considered as 
endemic in the general population. 

There is suspicion today that the antibiotic -resistant "hospital strains" 
of staphylecocci are significantly more virulent than "community strains. " 
For this reason, hospital-acquired staphylococcal disease is being widely 
recognized as a health problem of increasing import. Because many hos- 
pitals already have experienced a serious problem with staphylococcal in- 
fections, it is vinderstandable that patients upon discharge from the hospital 
may serve as potential spreaders of resistant strains to the community at 
large. Hospital and public health authorities are justly concerned with both 
the real and potential impact of this disease on the general population. 

A basic approach to the solution of the problem embraces adequate 
training of all 'personnel — physicians, nurses, laboratory and environmental 
health workers — who will be called upon to deal effectively with it. "Selected 
Materials on Staphylococcal Disease, Public Health Service Publication 
No. 627, " October 1958, compiled by the Communicable Disease Center, 
U. S. Public Health Service (available from Superintendent of Docunrients, 
U. S. Government Printing Office, $1.25 per copy), is designed to provide 
useful information to instructors and others selected to play a role in teach- 
ing programs at naany levels of operations. This publication contains the 
following selected reprints. 



32 Medical News Letter, Vol. 33, No, 10 



Ajnerlcan Academy of Pedlatrica ; 

February 1958: SPECIAX REPORT ON "STAPHYLOCOCCAL INFECTIONS IN THE 
NEWBORN" - COMMITTEE ON FETUS AND NEWBORN - AAP 

March 1958: SUGGESTIONS FOR CONTROL OF STAPHYLOCOCCAL INFECTION 
IN NEWBORN NURSERIES 

American Hoapital AflBOclatlon ; 

(Reproduced from Vol. 48, pp. 1071-1074, American Journal of Public Health) 
Ivlay 21, 1958 (Bulletin 1): PREVENTION AND CONTROL OF STAPHYLO- 
COCCUS INFECTIONS IN HOSPITALS 

Amerjcan Journal of Public Health ; 

Vol. 47, pp. 990-994, T. E. Shaffer, R. F. Sylvester, J, N. Baldwin, M. S. Rheine: 
STAPHYLOCOCCAL INFECTIONS IN NEWBORN INFANTS. R. REPORT OF 19 
EPIDEMICS CAUSED BY AN IDENTICAL STRAIN OF STAPHYLOCOCCUS 
PYOGENES 

Vol. 48, pp. 277-318, R. T. Ravenholt, O. H. Ravenholt, F. H. Wentworth, 
A. L. Miller, B. B. Wentworth, F, R. Fekety, L. Buchbinder, E. L. Shatfer, 
S. Goldberg, H. P. Price, L. A. Pyle, W. A. Murray, G. E. McDaniel, M. 
Reed: STAPHYLOCOCCAL SYMPOSIUM 

STAPHYLOCOCCAL INFECTIONS IN THE HOSPITAL AND COMMIWITY 
R. T. Ravenholt and O. H. Ravenholt 

OBSERVATIONS RELATIVE TO THE NATURE AND CONTROL OF EPIDEMIC 
STAPHYLOCOCCAL DISEASE 

F. H. Wentworth, A. L. Miller, and B. B. Wentworth 

CONTROL OF AN OUTBREAK OF STAPHYLOCOCCAL INFECTIONS AMONG 
MOTHERS AND INFANTS IN A SUBURBAN HOSPITAL 

F. R. Fekety, L. Buchbinder, E. L. Shaffer, S. Goldberg, H. P. Price, 

and L. A. Pyle 

EVALUATION OF THE PHONE SURVEY IN AN OUTBREAK OF STAPHY- 
LOCOCCAL INFECTIONS IN A HOSPITAL NURSERY FOR THE NEWBORN 
W. A. Murray, G. E. McDaniel, and M. Reed 

Vol. 48, pp. 1071-1074, The American Hospital Association: PREVENTION AND 
CONTROL OF STAPHYLOCOCCAL INFECTIONS IN HOSPITALS 

Aanala of Internal Medicine : 

Vol. 43, pp. 287-298, L. Welnstein; THE CHEMOPROPHYLAXIS OF INFECTION 

Vol, 45, pp. 738-781, D. E. Rogers: THE CURRENT PROBLEM OF STAPHY- 
LOCOCCAL INFECTIONS 



Medical News Letter, Vol. 33, No. 10 33 



BritlBh Medical Journal: 

Vol. 1. pp. 69-73, R. Hare, M. Ridley: FURTHER STUDIES ON THE TRANS- 
MISSION OF STAPH. AUREUS 

Canadian Medical AaBoclation Journal : 

Vol. 75, pp. 371-380, H. Starkey: CONTROL OF STAPHYLOCOCCAL INFEC- 
TIONS m HOSPITALS 

Journal of the American. Medical Asaoctation : 

Vol. 164. pp. 1733-1739, D. N. Wysham, W. M. M. Klrby: MICROCOCCI 
(STAPHYLOCOCCI) INFECTIONS IN A GENERAL HOSPITAL 

Journal of Clinical Pathology ; 

Vol. 9, pp. 115-127, E. S. Anderson, R. E. O. WiUiamB: BACTERIOPHAGE 
TYPING OF ENTERIC PATHOGENS AND STAPHYLOCOCCI AND ITS USE IN 
EPIDEMIOLOGY 

Journal of Laboratory and Clinical Medicine : 

Vol. 45, pp. 935-942, M. H. Lepper, G. G. Jackson, H. F. DowUng: CHAR- 
ACTERISTICS OF THE MICROCOCCAL NASAL CARRIER STATE AMONG 
HOSPITAL PERSONNEL 

Journal of Pathology and Bacteriology ; 

Vol. 78, pp. 253-259, S. K. R. Clarke: NASAL CARRIAGE OF STAPHYLO- 
COCCUS AUREUS 

Lancet: 



Vol. 2, pp. 786-794, R. Blowers, G. A. Mason, K. R. Wallace, M. Walton: 
CONTROL OF WOUND INFECTION IN A THORACIC SURGERY UNIT 

Vol. 2, pp. 885-891, L. Colebrook: INFECTION ACQUIRED IN HOSPITALS 

New England Journal of Medicine i 

Vol. 255, pp. 787-794, C. W. Howe: PREVENTION AND CONTROL OF POST- 
OPERATIVE WOUND INFECTIONS OWING TO STAPHYLOCOCCUS AUREUS 

Surgery, Gynecology and Obstetrics : 

Vol. 106, pp. 1-10, H. T. Caswell, K. M. Schreck, W. E. Burnett, E. R. 
Carrington, N. Learner, H, H. Steel, R. R. Tyson, W. C. Wright: BAC- 
TERIOLOGIC AND CLINICAL EXPERIENCES AND THE METHODS OF CON- 
TROL OF HOSPITAL INFECTIONS DUE TO ANTIBIOTIC RESISTANT STAPHY- 
LOCOCCI 

sji: sjc 5|< sit ^ :{; 



J- 



34 Medical News Letter, Vol. 33, No. 10 



New Four in One Antigen 

The new four-in-one antigen to immunize preschool children against 
poliomyelitis, diphtheria, pertussis, and tetanus was licensed under the 
Public Health Service Act on March 25, 1959. These combined antigens 
are designed for young children only and it is not advisable to give them to 
older children and adults because of their greater sensitivity reactions to 
diphtheria toxoid in full dose. 

Two manufacturers were licensed: Merck, Sharp, and Dohme; and 
Parke Davis and Company. (ComDisBr. PrevMedDiv, BuMed) 

Venereal Disease Epidemiologic Report 

The U. S. Public Health Service has recently revised the venereal 
disease contact report form. The new Venereal Disease Epidemiologic 
Report, PHS-2936, 6-58, replaces PHS-142I, Rev. 3-5^3. It is expected, 
that all activities will use the new form by 1 July 1959. BuMed Inst. 6222. 7, 
Venereal disease contact, interviewing and reporting, will be revised accord- 
ingly. 

^ ^ :^ ^ ^ ^ 

Basic Facts for Safe Boat Trailing 

While spacemen shoot for the moon, American earthlings are beating 
a super-octane track to the water. By the time they launch jet styled boats, 
don water skis, aqua Iiuigs and goggles, and grab fish spears, they looklike 
something the spacemen might meet on the moon, America's grounded 
masses are having fun. In fact, 35 million of them are making boating the 
nation's top family sport. In 1957, there were 3, 360, 000 outboard boats in 
use plus 2, 375,000 smaller boats which could be used with outboard power. 
The biggest boon to the outboard skipper who can't afford, doesn't want, or 
can't have a mooring spot for his craft is the boat trailer. It will get the boat 
fron^ the back yard to the water if the following basic facts for safe boat trail- 
ing are observed: 

1. Match the trailer to the boat and the car. Look for the Outboard 
Boating Club of America (OBC) weight capacity rating and if the boat comes 
within 100 pounds of it, for added safety, get the next larger trailer. Remem 
ber that a motor, luggage, and extra gear will probably be loaded in the boat. 

2. Check your trailer with requirements of applicable state motor vehi- 
cle laws. The Uniform Vehicle Code lists the following special safeguards: 

Tail Lamps. One light visible for at least 500 feet. 



Medical News Letter, Vol. 33, No. 10 35 



Other Lighting. Trailers weighing 3000 pounds gross or less, also 
should have two reflectors, one on each side; if over 3000 po\inds, addi- 
tional clearance and side marker lamps. AH trailers should have a stop- 
light if passenger car stoplight is obscured. 

Brakes, Trailers over 3000 pounds should be equipped withbrakes 
which are adequate to control their movement and operated from the tow- 
ing vehicle. Brakes should work automatically in event of accidental 
breakaway. New trailers for highway use — except semi-trailers less than 
1500 poiands — should have service brakes on all wheels. 

Width. Total outside width of any vehicle or load should not exceed 
8 feet. 

Load. No shifting or dropping allowed; loads must be secure for 
transport on the highway. 

3. For maximum safety, couple the boat trailer to the car with a frame 
hitch instead of a bumper hitch. The Society of Automotive Engineers (SAE) 
approves the use of a bumper hitch for trailers under 2000 potmds gross 
weight, but recommends a frame hitch for trailers over that weight. All 
couplings should be securely mounted by bolting, welding, or riveting. 
Don't take a chance on a makeshift arrangement. The SAE also recom- 
mends that couplings be equipped with hajid locks which won't come apart 
during travel, and that the hitch be designed so it can be disconnected 
regardless of angle of trailer to towing vehicle. 

4. To coast securely along waves of concrete and asphalt from yard 
to water, use a hitch safety chain which most states require by law. Get 
out and check the hitch and bolt tie-downs whenever stops are made. 
Loosen the tie -downs to reduce strain on the boat if stopover is for a 
long time. Make sure that the trailer, boat, and motor are insured. 

5. To navigate the highway without scuttling the rig, make sure when 
passing that there are no oncoming cars, then swing wide. Use an out- 
side rear view mirror if the boat blocks vision on the inside mirror. Be 
alert for landlubber pedestrians and jaywalkers who might see the car, 
but bang into the side of the trailer. When stopping, allow plenty of space 
for trailer and boat too. Travel slower than usual ajid practice braking 
at different speeds. Give clear signals if blinker lights are hidden by the 
boat. 

6. To launch an outboard, the driver needs a keen sense of direction 
and, if possible, a guide standing at the rear of the trailer to call out 
instructions. Back SLOWLY into the launching site at a right angle. To 
make the rear of the trailer go to the right, steer left; to go left, steer 
right. If the site is natural or unimproved, pick a sloping spot firm 
enough to give a lot of tire traction. If it is sandy or muddy, better 
traction can sometimes be gained by deflating the tires slightly, (Replace 
air in tires as soon as possible. ) 



36 Medical News Letter, Vol. 33, No. 10 



Boats Away . Three steps into the water: (1) Remove the rear tie- 
down when a few feet from the water's edge. (2) Tilt the motor up and 
unlock the bow winch, but keep the boat snubbed tight. (3) Back up until 
the trailer wheels are an inch or two in the water, turn off the ignition, 
set the hand brake, put the car in gear, and give the boat a firm push 
down the trailer. 

Legislation and Specifications 

Laws governing trailer operations are established by the state. The 
National Safety Council recommends that the Uniform Vehicle Code be used 
as a guide by states when drafting legislation on operation and equipment of 
motor vehicles and trailers. The Code may be obtained from the National 
Conrjmittee on Uniform Traffic Laws and Ordinances, Sheraton Building, 
711 14th St. N. W., Washington 5, D. C. 

The Outboard Boating Club of America composed of leading outboard 
nnanufacturers has developed standards for design and manufacture of boat 
trailers. Trailer builders have agreed to test their products for up to 50% 
niore than their recommended capacity and to document the test with an 
affidavit to the industry group. For further information, write; Outboard 
Boating Club of America, 307 No. Michigan Ave. , Chicago 1, 111, 

The Society of Automotive Engineers has published recommended prac- 
tices for passenger car trailer couplings. For information, write to: The 
Society of Automotive Engineers, Inc., 485 Lexington Ave. , New York 17, 
N. Y. (Traffic Safety, 52: 15-16, August 1958) 

NOTE ; It is recommended that the foregoing be reproduced in Station 
newspapers. 

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Dishwashing Machine Operation Aboard Ship 

(A few pointers are presented herein to assist in the proper operation of 
dishwashing machines; for obtaining clean, dry, and sanitary mess gear; 
and for the correct stowage of the mess gear aboard ship. ) 

Pre rinsing enables the dishwashing machine to do a better washing 
and sanitizing job. Silverware should be soaked, preferably in cold water, 
prior to being racked and placed in the dishwashing machine. All mess gear 
should be scraped and then prerinsed in cold water prior to being placed in 
the dishwashing machine. The Bureau of Ships, as funds permit, is pro- 
viding garbage grinders fitted with prerinsing facilities in those spaces 
equipped with dishwashing machines. However, prerinsing operations should 



Medical News Letter, Vol, 33, No. 10 37 



not be delayed iintil installation of the new equipment; it is recommended 
that temporary prerinsing facilities be rigged in the compartment containing 
the dishwashing machine rather than in a passageway. 

When mess gear is prerinsed, wash water temperature may range 
from 150*^ to 160** F. "When mess gear is not prerinsed, wash water tem- 
perature should be kept at approxim^ately 140** F. to avoid baking food resi- 
dues on the surface of the mess gear. 

Effective sanitizing of mess gear is accomplished when the tempera- 
ture of the final rinse water is 170^ F. or higher. As a safeguard, dish- 
washing machines aboard Navy ships are fitted with a thermostatic switch 
to prevent operation of the machine when the temperature of the final rinse 
water drops below 180** F. The temperature of the final rinse water also 
governs the drying time of the mess gear when it is removed from the mach- 
ine. Consequently, a high temperature final rinse water (200<> F. } will cause 
the mess gear to dry more rapidly and thoroughly than a low temperature 
final rinse water (180° F. ) ' • 

Detergent concentration in the wash water is very important and must 
be maintained at 3% to be fully effective. Guidance in the manual feeding of 
detergent to the wash water to nnaintain a 3% concentration is contained in 
Bureau of Ships Publication NavShips Z50-522, Operation and Maintenance 
of Dishwashing Machines, There are various detergent dispensers and meters 
on the market for automatically maintaining or indicating the detergent concen- 
tration in the wash water of dishwashing machines. However, these units re- 
quire frequent calibration and repair and their use is not recommended. 

It is particularly important that dishwashing machines be kept clean. 
Disassembly of spray arms, removal of scrap trays and spray curtains, and 
a thorough cleaning of the machine inside and out after each period of use will 
keep the machine operating effectively at all times. 

Mess gear should be placed in the dishwashing machine racks so that 
the various items will not retain water, i. e. , cups and bowls should be placed 
in the racks upside down so that the water will run off. The dishwashing nnach- 
ine rack for compartmented mess trays, currently in use, has sufficient slots 
for holding twelve (12) such trays. However, washing action will be more 
thorough if only six (6) trays are placed in each such rack by using the odd 
numbered slots (1, 3, 5, 7, 9 and 1 1 or 12). As each rack of mess gear is dis- 
charged from the dishwashing machine it should be raised slightly off the 
dresser and then dropped back on the dresser to dislodge the large droplets 
of water from the mess gear and facilitate drying. The rack of niess gear 
should then be moved away from the machine and allowed to stand for at least 
one minute to dry. The use of drying towels is prohibited. After drying, the 
mess gear should be returned to the mess gear lockers and racks and stowed 
in an inverted (upside down) position. Silverware is generally stowed flat in 
stainless steel boxes or containers. When so stowed, the knives, forks, and 
spoons should each be in separate containers and with the handles toward the 



38 Medical News Letter, Vol. 33, No. 10 



front of the container. Where cylindrical upright stowage containers are 
provided for silverware, each of the items should likewise be stowed in 
separate containers and with the handles up. All mess gear, when stowed, 
should be protected from contamination by dust, splash, coughing, sneezing, 
and handling. 

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Benefjt.s of Golf 

Golf, among other beneficial effects, leashes anxiety, raises morale 
and t9nes up the bodily functions. j , 

Gplf affords fresh air and sunshine, general, bojiy pxerc^ge of varying , 
degrees, stimulation of the mind by the mere process of watching a little 
white ball, and the satisfaction of personal gain and achievement by the chal-. 
lenge it presents. However, these items do not constitute the sole benefits. 
As a man plays on the course, he rests; his tensions find an outlet and de- 
crease; his guards are dovv , so to speak, and he becomes more congenial with 
his fellow man whether he is aware of it or not. 

A familiar picture to everyone is the individual who upon returning honne 
from a hard day's work, bored, perhaps unhappy, and tired, flops himself on 
the nearest couch too exhausted to eat. In this state of near stupor he lies 
when suddenly the phone rings and a fellow player extends an invitation to 
play a round of golf. He becomes electrified with energy; with a spring in his 
step, a song in his heart, he showers his loved one with endearing terms and 
asks "'What's there to eat? I'm starved. " He is looking at the world with rose- 
colored glasses. This alone is enough to convince anyone of the beneficial 
psychologic innpact of golf. 

An individual who handles his aggressive drives poorly or has no suit- 
able outlet to vent these drives will find release and discharge of these ag- 
gressions by participating in a sport involving muscular activity. Golf 
furnishes this type of muscular and physical activity. Hitting a golf ball 
viciously may serve as a vicarious release of hatred toward a dominating 
person, such as an employer with no harm coming to the person, boss, or 
the job. 

The author knows of no other widely played sport where there is a 
willing intermingling of all strata of socio-economic class, race, color, or 
creed. In this game that supplies recreative enjoyment, the golfer is interest- 
ed primarily in whether the members of his foursome are fair players who are 
acquainted with the etiquette of the game. 

The degree of exercise offered by golf plays a role in preventive med- 
icine. Lack of muscular activity miay result in weak muscles and inadequate 
egress for nervous tension. This in turn may be responsible for various forms 
of neck and shoulder pain, backache, and headaches, as well as other forms of 



Medical News Letter, Vol. 33, No. 10 39 



"psychosomatic" disturbances. The consensus among medical men is that 
heart attacks (coronary thrombosis), along with other factors, appear to 
be associated more with lack of physical activity and poor health habits 
than hard work and over -exercise. As a matter of fact, golf is often pre- 
scribed as a means of rehabilitation for those patients who have suffered 
and recovered from a heart attack. Morris and Heady reported in the 
British Journal of Industrial Medicine that sedentary habits seem to be re- 
lated to increased death rate in the middle age group. 

A significant relationship was found to exist between physical activity 
and fitness and academic achievement in a group of male freshmen at the 
State University of Iowa. This study was conducted by Weber and published 
in the Resident Quarterly Medical Journal, The findings clearly showed that, 
in general, good grades accompanied physical fitness. 

The imiportance of exercise as a factor in weight control is borne out 
by a study reported by Dorris and Stunkard in the American Journal of Med- 
ical Sciences. They studied the degree of physical activity of overweight 
women as compared to those of normal weight. It was fotuid that the over- 
weight group, on the average, walked less than half as much as those in the 
normal weight group. Riedneau and associates demonstrated and noted in 
Medical Research and Nutrition Laboratory Report No. Z09, Fitzaimons 
Army Hospital, the relationship of exercise to overweight in relation to food 
intake and physical activity of a group of high school girls. A comparison of 
the caloric intake of the overweight with that of the non -overweight revealed the 
surprising fact that the caloric intake of the overweight was lower. Both 
groups were relatively inactive, but the overweight girls spent much less time 
in physical activity than the normal weight girls. 

That the mere participation in physical activity will necessarily make 
one physically fit is not to be concluded because many other facets are in- 
volved. However, it is a means by which one may attempt to achieve such 
a desired goal. Golf offers this means. Through such practices, exercise 
and general physical activity may become part of the way of life, promoting 
good health and preventing or delaying certain mental and physical disorders. 
(LTJG A. R. Tortora MC USNR, Benefits of Golf: Golf World, October 24, 1958) 



U. S. Naval Medical Research Unit No. 2 

The information quoted below is published to indicate, to a degree, 
some of the research work being conducted by this Unit. 

"During March 1959, the U. S. Naval Medical Research Unit No. 2 
conducted a very successful expedition to Lan Yii {Botel Tobago), a 
small island off the southeast coast of Taiwan. The group, directed 



40 



Medical News Letter, Vol. 33, No. 10 



by Captain Francis M. Morgan MC USN and Commander Robert E. Kuntz 
MSC USN, continued geomedical and biological studies which are current- 
ly in progress on Taiwan and in covintries of Southeast Asia. 

The population which consists of aborigines of the Yami tribe, unlike 
others in the area, has remained more or less isolated through the years. 
Emphasis was given to a study of diseases, medical conditions, and the 
parasites in a sizable sannple of the 1750 islanders. Dr. C.H. Chen of 
the Taipei Tuberculosis Control Center and Dr. Alan Penington, WHO 
Consultant, nnade an extensive survey for tuberculosis. Helminth para- 
sites and blood smears were obtained from approximately 500 animals 
examined. ■' (NMRU #2) 

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